Nursing and Midwifery

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    Living with acute coronary syndrome and prediabetes : an interpretive description of complex illness : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Wellington, New Zealand
    (Massey University, 2013) Van Wissen, Kim
    The purpose of this research is to reveal the experience and interpretation people have of cardiovascular disease (CVD) and prediabetes as complex illness. CVD and diabetes are both increasing in prevalence in New Zealand and globally. Prediabetes is known to be precursory to type 2 diabetes; CVD and prediabetes are fast becoming an established comorbidity. As the prevalence of complex illness soars, the experience and interpretation people have of their condition requires deeper appreciation by nurses as members of a practice discipline. This doctoral research draws attention to the experiences as interpreted by participants and subsequently by the researcher, using interpretive description informed by Gadamer and Merleau-Ponty. Thirty three participants with CVD and prediabetes were recruited into this study. Open ended interviews were undertaken in hospital before discharge and then approximately 9 months later in the community. Interviews were transcribed, data managed by NVivo 9 software, data analysed using thematic analysis, and a thematic framework was developed to organise themes. The overarching theme is in/conspicuous detail indicating the visible and the invisible elements of complex illness. The two major themes, invisible disequilibrium and dialogue as caring, foreground further subthemes and embedded subthemes. The major theme invisible disequilibrium describes the experience of illness and is supported by three subthemes: losing equilibrium, becoming embattled and making sense of evolving illness. The second major theme dialogue as caring interprets the experiences participants had and is supported by subthemes: restorative dialogue, caring and constructing illness. Major findings indicate that complex illness is heterogeneous and participants were continually working with and making sense of the conspicuous and less conspicuous detail of ‘the whole’. Further findings include the proclivity of risk (choice) as a function of participants’ lifestyle such as diet type, activity levels, understanding of medications, plus how this risk may in the longer term cause disease and illness. A third major finding is that participants focussed on self-care as part of their construction of illness. This research provided insights into the experiences of people with CVD and prediabetes. It also showed that complex illness is the occurrence of an intricate meshing of personal circumstances, signs and symptoms that requires attending to needs as identified by the patient. This continues the debate concerning how illness affects the lives of individuals, potentially influencing future service planning.
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    Making sense of the Director of Nursing structural positioning in New Zealand public hospitals (2006-2012) : a thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, Massey University
    (Massey University, 2013) Hughes, Kerri-ann
    This dissertation reports on research examining and analyzing nursing leadership structures in New Zealand public hospitals, and in particular, the Director of Nursing (DoN) structural positioning. Leadership in hospital nursing is critical if the profession is to meet the challenges facing health services in the 21st century. The research has been undertaken using case study methodology and focuses on how organizational decision-making structures have impacted on nursing leadership in public hospitals. ‘Sense-making’ has been used as a theoretical construct to understand both the formal and informal structures that influence organizational decision-making. Phase one of the research involved examining twenty District Health Board (DHB) organizational and nursing charts. In phase two and three, the Directors of Nursing (DoNs) and the Chief Executive Officers (CEOs) were surveyed using a series of demographic and qualitative questions to draw out understanding of the Director of Nursing (DoN) role. The research has found that the constructs of power and authority influence the decision making processes at the executive level of the DHB. An analysis of the data indicates that the current structural positioning of the DoN is hindered by the existing dual accountability line reporting structures in DHBs and this is a barrier to alignment with Magnet hospital principles which provide evidence of effective patient outcomes. The focus primarily adopted by District Health Boards on professional line reporting only for nursing is not conducive to achieving effective and safe patient outcomes as it removes authority from the DoN and yet places unrealisticexpectations on accountability of how the DoN can achieve effective and safe patient outcomes within the public hospital setting.
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    He iwi ke koutou, he iwi ke matou, engari i tenei wa, tatou, tatou e = You are different, we are different, but we are able to work together : Family Partnership as a model for cultural responsiveness in a Well Child context : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Albany, New Zealand
    (Massey University, 2013) Tipa, Zoe Kristen
    In 2006 the Royal New Zealand Plunket Society embraced a model of communication and practice titled Family Partnership. The Family Partnership model and training is designed to develop the communication skills of professionals working with families in order to acknowledge and enhance the capabilities of parents. It is acknowledged that the degree to which a service is culturally safe is defined by the individual receiving the service. Nurse leaders, educators and peers are consistently required to make judgements as to the extent to which the nurse being observed is culturally safe, without obtaining client feedback. This research examined whether the Family Partnership model could be considered a model for cultural responsiveness with the dual benefit of providing a platform to more accurately assess the cultural competence of Plunket nurse practice. An evaluation design and methodology was used to determine the relationship between Family Partnership training for Plunket nurses in relation to Māori health outcomes. There were two phases in the data collection process. In phase one an online survey was completed by a group of Plunket nurses who had completed Family Partnership training along with a group that had not completed Family Partnership training. Phase two included ten observations and interviews with Plunket nurses and Plunket clients who identified as Māori. A combination of evaluation tables to determine merit and thematic analysis were used for the analysis of the mixed methods data. The results were presented in three sections relating to Plunket nurse practice, client experience and the impact on Plunket as an organisation. All Plunket nurses who participated in the research believed that Family Partnership had a positive impact on their clinical practice. The extent to which their practice had changed was difficult to determine, however the need for ongoing updates in Family Partnership was strongly indicated. Māori Plunket clients were generally satisfied with the Plunket service and their responses aligned with the concepts outlined in Family Partnership communication theory. The relationship between the findings and the principles of the Treaty of Waitangi were highlighted. This research has indicated that cultural responsiveness can be defined as the way in which a service identifies and attempts to meet the needs of the individual. It has discussed the complexity around what constitutes a health outcome for Māori clients and ultimately how cultural competence may be better assessed in practice.
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    Living at home after 95 years : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Albany, New Zealand
    (Massey University, 2013) Russell, Julia May
    Globally the number of older people is increasing with the largest increases occurring in those aged over 85 years. Historically little has been written about this group and because of increasing numbers more information is needed to inform the development of future services. The question was how people live in their own home independently after 95 years? This work was informed by narrative gerontology overlaid with a critical gerontological lens to give voice to this group. Through a purposive sampling strategy ten narrators were identified and were interviewed using a semi-structured format. Data analysis was undertaken using thematic analysis with three themes; staying socially connected, managing the physical environment and keeping and ageing well emerging. Further to this, there were associated subthemes, which support and further illuminate the detail of the theme itself. These findings also unsettled the ageist, biomedical view of the oldest-old and what we think we know about them. In this study the narrators gave voice to their lives and what contributed to them living at home independently. Not everyone will live to 95+ years and how this was achieved by this group was the result of their entire lives and showed itself in the resilient characters of these narrators. All of whom considered the benefits of social connectedness, hard work and keeping well as reasons for living independently at home. As well as this, the need to stay mobile and the current contribution of help and support from both family were contributing factors. This research provides considerations for changes in not only the way we view those over 95 years but also the way we consult and provide services to them. There is an urgent need to promote achieving resilience, eliminate ageism and promote a more balanced view of the oldest-old.
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    BSMC : is there room for me? : an exploration of nursing leadership in primary health care : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Auckland, New Zealand
    (Massey University, 2012) Calverley, Rachael
    The unpredictability of health in a dynamic climate can result in a multiplicity of challenges. Indeed unpredictability has been referred to as the essence of creativity. Strong leadership in healthcare and importantly nursing is crucial to seeking solutions to organizational change especially when decision making will impact on the population’s health. By influencing policy objectives through leadership, nurses have the opportunity to develop strategies that make a difference to future complex problems. With the implementation of the Governments Better Sooner More Convenient (BSMC) policy agenda and principles underway from 2008 onwards, to reframe primary health care services, a series of key principles emerged including: a more personalized primary health care system with services moved closer to home; reduction in demand on hospitals and a package of services centred on integrated family health centres, with nurses taking a key role in shifting services from the secondary to primary care needs of patient support. From seventy health collective submissions positioning themselves to address these principles, nine were selected to move through to the next stage of development. The applications from all of the successful organizations referred to the need for improved multi-professional working and/or the importance of the nursing workforce to the BSMC agenda. Importantly, it would appear that a high quality nursing leadership function within the BSMC health collectives developing BSMC service configurations would be required to meet their goals. The purpose of this study was to explore with nurse leaders how they were able to contribute to these evolving primary health care collectives and changes that influenced the development of new or reviewed services, in addition to gaining insight into their challenges and opportunities as nurse leaders. The literature suggests a move away from the post heroic model of leadership and refers more frequently to coalitions of experts or leaders as a collective intelligence. These emerging characteristics represent a distributed leadership model that is leadership shared across varying people, professions and roles. It is this distributed model of leadership that provided a conceptual framework and a clear point of reference for this study. A qualitative approach derived from an interpretive perspective was the methodology chosen for this research. Eight out of nine potential nurse leaders involved in each of the regional health collectives participated in telephone interviews and communicated with the researcher via email networks. Theme identification was the essential task for the analysis process. Four key themes were identified with subthemes: politicization (power to influence), infrastructure (teams and education/training), coalitions of leaders (communication and relationships) and resilience (battling and visibility). The findings suggest on-going challenges to nurses leading in primary health care which include fragmentation among nurses, variable investment in regional nursing infrastructure, interdisciplinary relationship issues and limited training to develop future nurse leaders. Addressing these results requires clinical, strategic and professional nursing leaders to work within fora that are unified, cohesive and collectively agreed on their purpose.
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    In search of nursing : the long-term impact of the New Zealand health reforms on ward nursing : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Manawatu, New Zealand
    (Massey University, 2012) Teekman, Englebert Cornelis
    This thesis began with my curiosity about why, despite repeated attention to nurses’ health assessment skills (at undergraduate and professional development level), it has remained an under-utilised skill. A focused ethnography was conducted in six acute wards of a provincial New Zealand hospital. Twelve registered nurses were observed and interviewed in the first phase of the research and multiple additional primary data sources were utilised. Early findings indicated that nurses did not undertake health assessment and raised much broader questions about the nature of ward nursing practice and the amount of control ward nurses have over their work environment and their own nursing practice. The research was extended to include seven stakeholders, senior nurses who had good insight and knowledge of ward nursing practice. A structuration theory lens was applied to assist in the analytic process. The findings of this research reveal the long-term impact of the NZ health reforms on ward nursing practice. The introduction of generic management principles and the continuous restructuring of the health care environment have impacted on nursing practice and reduced nurses’ autonomy. Nurses have come to rely on standardised documented processes to provide essential care, relying significantly less on knowledge of a patient’s actual health status. Much recent local and international quantitative research has revealed a number of concerning findings about the reduced time nurses spend at the bedside, the complexity of nursing work flow, the increase in interruptions, missed nursing care, and the vital role nurses have in preventing many adverse events and unexpected deaths. This thesis provides a rich qualitative understanding of the circumstances behind these quantitative findings and reveals that nurses are now struggling to provide care consistent with the ethos of nursing. I argue that challenging the nature of nurse education will not improve nurses’ ability to deliver nursing care. Instead I argue that the current acute ward environment does not support registered nurses to provide the nature of care for which their education has prepared them.
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    The life and ageing experiences of gay men over the age of 65 in New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Albany, New Zealand
    (Massey University, 2012) Kushner, Bernard Dean
    BACKGROUND What does it mean to age as a gay man in New Zealand? Until recently, this has been a question difficult to answer as there were no studies completed in New Zealand regarding this topic and thus, this principal work explores this question. AIMS The purpose of this study was to explore the life and ageing experiences of gay men in New Zealand over the age of 65 years. Its three aims were to: • Critically explore the narratives of gay men over 65 years. • Identify areas of support that these men might need as they age, and • Inform professional health practice about the care needs of older gay men. METHODS This enquiry has utilised two theoretical frameworks, narrative gerontology informed by critical gerontology melded together in which to explore the above aims. Data were gathered from semi-structured interviews with 12 men from the ages of 65-81 years of age. Analysis of the data were completed by thematic analysis. FINDINGS There were two main themes that became evident in this project and these were emergence of the gay self and the ageing experience. CONCLUSION Resilience was a significant factor in how well the men aged even in an environment of homophobia. Being independent and having a strong social support network were factors that assisted them in ageing in the absence of a partner. Other ageing concerns that surfaced that were not sexual orientation specific were dealing with loss, death, financial well-being, and the ageist attitudes of others. The men were wary of sharing their sexual orientation with too many healthcare professionals and they feared having to potentially hide their sexual orientation again if they ever needed to go into a long-term care setting in the future. This study highlights the unique experiences of ageing among older gay men in New Zealand. Healthcare professionals as well as nurse educators and researchers must recognise the unique history of this group of men and any conflicts this group may have with others of different orientation in order to assist them to age well in a safe social environment.
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    Hei aha nga whakaaro o Ngati Ruanui mo te Whanau Ora? : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy (Nursing) at Massey University, Palmerston North, New Zealand
    (Massey University, 2012) Campbell-Knowles, Te Moana
    In Aotearoa New Zealand poorer health outcomes for Māori have been well documented. There is growing evidence that limited contact between whānau members has a potential negative impact on the health and wellbeing within the whānau. The term Whānau Ora has been widely used and variously defined by Māori over many years however there is no single shared definition of Whānau Ora, and little understanding about how it can be implemented by Māori health providers as a service delivery framework. This research expands on existing knowledge of Whānau Ora by identifying definitions, gathering data about Whānau Ora values and concepts, cultural beliefs and practices. This research is informed by the worldview of healthcare for Māori. A number of hui (meetings) were held where Ngāti Ruanui iwi members were consulted and ten Ngāti Ruanui participants were interviewed. These participants identified meanings of Whānau Ora that included ‘being Māori’ and who they are (whakapapa) and how this translates to ‘how they live’ (Matauranga Māori), ‘self-definition’ (tino-rangatiranga) and how Whānau Ora is the ‘way forward’ to address past and present issues such as colonisation and inequalities. This research employed a Māori-centred qualitative methodology which allowed Māori and Western belief systems their own integrity whilst working side by side, utilizing the energy of the two systems. Localising the research to Ngāti Ruanui Iwi members was intentional, to understand what members considered important. As the integrity of the participants was a central concern in the research, a methodology was adopted that was respectful and valued the participant’s worldview. Participants regarded Whānau Ora as a mechanism to assist whānau to “move on”, and advance as Māori. Whānau Ora was also regarded as an important future model of health that has the potential ‘do away’ with disparities and assist Māori in their efforts to strive for good health. The research concluded that Māori health outcomes will be much improved when they are delivered in ways that meet the cultural needs of Māori. The roles and responsibilities of the Crown must ensure that these changes develop and are done in collaboration with Māori organisations themselves which will ensure that any changes reflect the philosophies of Whānau Ora: optimal wellbeing.
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    A qualitative exploration of environmental and relational factors affecting service user involvement from the perspective of community mental health nurses : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Palmerston North Campus, New Zealand
    (Massey University, 2012) Brown, Vicky Keryn
    Mental health policy and clinical guidelines require service user involvement principles within clinical practice and service provision, yet few national studies exist to examine Mental Health Nurse’s (MHNs) viewpoints about its implementation. This qualitative research project asks the question ‘What are the environmental and relational factors which affect service user involvement in community mental health team settings from the perspectives of community MHNs?’ The research aims were: (1) Explore how the practice environment supports service user involvement; (2) Explore how they include, or not, service users in the provision of care; and, (3) To discuss how the group of community MHNs recognise and describe service user involvement. Central ethics approval was gained and eight community MHNs in two District Health Board’s (DHBs) with over 5 years experience were interviewed. Participant’s discussion was audio taped, transcribed and then analysed utilising a thematic analysis approach. From this analysis, two predominant themes arose. Theme one highlights the ‘relationship dynamics of practice’ through exploration of concepts of historical changes; conflicting relationships, influential attitudes and powerlessness. Theme two explores ‘strength based approaches’ from the participants perspectives and includes recovery; inclusive practices; challenging stigma and beliefs towards service user involvement. Mutual agreement about the benefits of service user involvement was identified. However, changes to funding, hierarchical mental health organisations, nurses’ education, stigmatising attitudes and lack of nursing identity have impacted on the implementation and support of service user involvement. Recommendations for further research and suggestions for nursing practice are offered through building nursing capacity, capability, quality and strengthening the profession.
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    Using a patient held record for home based palliative care patients : a case study research project : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University, Manawatu, New Zealand
    (Massey University, 2012) White, Denise
    A paper based patient[-]held record (PHR) was introduced by the study region’s district nursing service and hospice palliative care co-ordinators to promote continuity of care for home[-]based palliative patients. The inquiry has employed a case study research approach to gain greater understanding of the use, challenges and impact of this initiative from those who had or used the PHR. Through the use of semi-structured interviews and focus groups, patients, lay carers, and clinicians from the main groups providing community palliative services were asked about their views and experiences in relation to use of the PHR. The research suggests a PHR can bring a positive impact for palliative patients and their lay carers, particularly where used for sharing information with the patient and family, and between clinicians and services. When used for this purpose the PHR can assist clinicians to collaborate and co-ordinate care and to promote patient centred and empowering care. However, the findings also reveal that lack of engagement by clinicians with the PHR can lead to frustration and disappointment, particularly for those most connected to and invested in its use, carrying the potential to disrupt both therapeutic and professional relationships. The study revealed conflicting goals regarding the purpose of the PHR. Most clinician’s [sic] appeared to focus their use of it on promoting efficiency, primarily in the direction of value for the clinician and service. In contrast, most lay participants viewed their PHR as a tool to assist self-care and improve their chances to experience continuity. The results reveal that some well embedded ideologies, routines and rituals currently operating within the health sector have the power to constrain or restrain partnership and innovation. However, the position of the patient and family in their home appears to offer a degree of counteraction of power and agency which some patients and family had employed to influence and co-construct the use and function of their PHR with their home visiting clinicians.